Monday, December 24, 2012

Safe Healthcare and Bodily Integrity For All

Opposition to male circumcision need not be based on the claim that the operation is harmful, nor on the claim that it is more or less harmful than female genital mutilation (FGM), or various other processes. The facts that it is harmful, and can be more harmful than certain instances of FGM and other processes are important, but not as important as the fact that infant circumcision, like infant FGM, is a denial of the right to bodily integrity. Therefore it is no good claiming that it is cleaner, looks better, protects from diseases, etc. Those considerations, even if true, can not be used to deny the right to bodily integrity.

Many things are good for people's health and far fewer are campaigning for them, such as safe healthcare in developing countries. This is also a human right; hopefully safe healthcare rather than just any old healthcare. There is a lot of evidence that it is unsafe healthcare that causes much of the mortality and morbidity in countries with a high disease burden. We don't even need to carry out expensive research to show that safe healthcare improves health. So why the billions for circumcision, and the heavy handed campaigning, when there are more obvious and more urgent things that need to be addressed?

When it comes to the claim that circumcision reduces HIV transmission, there are several serious problems. For a start, it reinforces the view that most HIV transmission is sexual transmission, even though none of the randomized controlled trials excluded the possibility that some of the people who were infected were not infected through sex. If most HIV transmission is sexual it is unlikely circumcision will have much net benefit, especially when you consider that it is thought to increase transmission from men to women. But if most HIV transmission is not sexual, circumcision will very likely increase the risks that men face, given the conditions in healthcare facilities in high HIV prevalence countries.

Where FGM is banned, it is not permitted just as long as the conditions under which it is carried out are hygienic; it is not allowed if it is a cultural practice; the possibility that it might have some health benefits is not generally even discussed, except to deny that it has any health benefits. But mass male circumcision is aggressively promoted where many women can not even give birth in safe conditions, where people donating blood risk infection with HIV and hepatitis, where the majority of HIV infections occur in long term, monogamous relationships for which no serious sexual risks can be identified.

According to the arguments of the circumcision enthusiasts, every man in the world should be practicing male circumcision. But it's not much practiced in Ireland, or anywhere else in Europe. So why is it acceptable for rich countries to use foreign aid money to carry out mass male circumcision programs in African countries? Is it because we believe that, while HIV is mostly transmitted through male to male sex and intravenous drug use in rich countries, that it is mostly transmitted through unsafe heterosexual sex in African countries? Why do we believe that?

But if we even do a little superficial research, or read UN information leaflets, we must also know that conditions in health facilities in developing countries are unsafe, that blood and skin piercing instruments can be contaminated with HIV and other diseases; isn't it fairly telling that UN employees are issued with their own injecting equipment when going to developing countries? So how can we not believe than some HIV transmission occurs in African hospitals? And how can we believe that only about 2.5% of all HIV transmission in African countries is a result of unsafe healthcare, when the UN warns its own employees about these risks?

Even if the figure is as low as 2.5%, if health facilities are dangerous then half a million Africans could be infected from mass male circumcision programs alone. And it would be difficult to estimate how many infants and boys might be infected with HIV and other diseases through non-medical circumcision, which is what the majority receive. Are we so obsessed with 'African' sexuality that we think there are no other important HIV risks but sexual? The best way to reduce HIV transmission would be to prevent all risks, not just sexual risks. The UN has made a start in reducing the risk of infection among UN employees working in developing countries, but Africans would be wise to note the advice that is given out to non-Africans.

The problem is, of course, that health facilities have been all but ignored since the World Bank and IMF's 'structural adjustment policies' of the 1980s insisted that African countries needed fewer facilities, fewer health professionals, less money spent on training and lower salaries. There is vague talk about 'health systems strengthening' and other nice-sounding programs. But big donors still seem to favor vertical health programs, where separate, parallel health structures need to be set up for each initiative, whether it's polio, cholera, TB, lymphatic filariasis, onchocerciasis, HIV or whatever. Mass male circumcision is just another vertical program, each one destined to cost perhaps as much as real health systems, that people urgently need. And as for safe healthcare? No, that would be too much like development.

The UN is in an odd position because they claim that health facilities are safe enough for Africans as only 2.5% or less of all HIV transmission is a result of unsafe healthcare, but these facilities are not safe enough for their own employees. Even tourists going to African countries can purchase supplies of needles and syringes and they will find warnings about using health facilities in many countries in their guidebooks. It's no secret, just as long as you are from a wealthy country. Can we conclude that, not only are Africans almost uniquely susceptible to sexually transmitted HIV, even where conditions in health facilities are appalling, but also, foreigners from rich countries are uniquely susceptible to healthcare transmitted HIV? If so, then HIV is indeed anomalous.

My guess would be that the UN is telling the truth to its own employees about the dangers of health facilities in developing countries. Therefore, they must be lying when they claim that 80% of HIV transmission is a result of unsafe sex and about 18% is a result of mother to child transmission. So mass male circumcision programs will not reduce HIV transmission via sexual intercourse. On the contrary, they will probably result in increased HIV transmission through unsafe healthcare.

This is not entirely bad news. Since infant circumcision is a denial of the right to bodily integrity, will probably not result in a net reduction in HIV transmission and will cost a lot of money that could better spent on other diseases, mass male circumcision programs will clearly have to be stopped immediately. And that should free up scarce resources for more urgent issues, which should not be very difficult to identify.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


1 comment:

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